Fidelity and clinical competence in providing IMR 159 psychologists should be employed as IMR trainers. However, a previous study indicated that mental health professionals from diverse backgrounds were able to apply IMR with high fidelity, though sufficient training and continuous supervision were considered critical (41). Therefore, more specialized training and experience in these skills were required so that using role-play, modeling, and home assignments could become a routine activity at the sites participating in the current study. Implications of this study In addition to these relevant cognitive-behavioral techniques, the current study showed serious shortcomings in IMR trainers' adherence to the IMR model. These shortcomings were also shown in other defining IMR characteristics in more than half of the IMR groups each time. The IMR trainers concerned did not routinely follow up on goals set by participants, did not teach participants relapse prevention or coping skills, and did not incorporate behavioral tailoring to improve medication self-management. One practical approach would be applying the technique of systematically using fidelity-based feedback to shape IMR clinicians' clinical skills (20, 42). This means that training and supervision of clinicians in IMR should include information on clinicians' fidelity to the model, collected on a routine basis, preferably using objective methods (such as completing the IT-IS based on audio tapes of sessions). Using this information, directions can be provided for training specific competencies of clinicians to improve fidelity to the model. Originally, the primary evidence base for the development of the IMR program included research demonstrating the beneficial effects of cognitive-behavioral techniques, behavioral tailoring for medication, relapse prevention training, and coping skills training (4). In the Introduction, it was mentioned that one of the causes for variations in the results of the RCTs on IMR might have been differences in model fidelity (17-19). Therefore, poor fidelity to these IMR elements could have contributed to some of this variability in outcomes, including the lack of effects on symptomatic or functional outcomes other than illness self-management found for IMR in our own RCT (17). Strengths and limitations To our knowledge, this is the first study to examine both IMR fidelity and IMR clinician competence at the group and item levels using the IMR Fidelity Scale and the IT-IS. This helped determine the level of implementation of IMR elements and identify poorly implemented elements. This knowledge can be used for directing
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